ERYTHEMA PAPULATUM ET TUBERCULATUM. WITH FOUR DRAWINGS OF THE CASE DEPOSITED IN THE SOCIETY’S ROOMS. BY SILAS DURKEE, M.D. Bead before the Boston Society for Medical Improvement, October 8th, 1860. The Mrs. J. B. Peck, of Connecticut, was presented for examination. Her age is 54 years. She was born of healthy parents, both of whom are now living at the age of more than 80 years; is a tall, stout, well-built toman, and at the age of 45 weighed 160 pounds. She is intelligent and of good character. She has never been pregnant, has never had any uterine disease, and the menstrual function ceased at the usual period. She re- ports that ten years ago, and without any appreciable cause, a bright scarlet-colored eruption appeared upon the face, the trunk of the body and the extremities, producing but little inconveni- ence of any kind, excepting a moderate degree of heat and itch- ing, until the expiration of about ten months, when a succession of small bunches or lumps appeared and soon terminated in “ sores,” which (she states) her physicians compared to the pustules or sores of smallpox.* Each of these “ sores ” required, as near as the patient can recollect, from twelve to fifteen days for their en- tire development and disappearance. They yielded but little dis- charge of any kind, and ended in a dark incrustation or scab. They were not painful at any time, like boils, nor did they in any wise incommode the patient so as to deprive her of sleep or essen- tially to diminish her ability to attend to her domestic duties as usual; although, during this period of one year, she had a somewhat * Burgess, in his Treatise on Eruptions of the Face, Head, and Hands, relates, at page 23, a ease of erythema papulatum simulating smallpox. 2 impaired appetite, and lost several pounds of flesh. Only a few pustules (if this word is allowable, which I somewhat doubt) formed upon the face or body; but on the lower limbs they were nume- rous. On the right leg were sixty at one time. The eruption continued to present this quasi pustular character, or softening of the papules, for about two months, after which the patient remain- ed in fair health nearly five years. In 1856, the present disease began to show itself around the knee-joints, in the form of small, hard, red, solitary papules, slight- ly raised above the adjacent integument, and of a round or oval figure—mostly of the latter. In a few weeks they were developed on the chin and the front part of the neck; and in seven or eight months various portions of all the extremities were more or less involved in the eruption, which, from the account given by the pa- tient, appears to have been erythema papuLatum. The complaint has undergone repeated alternations of improvement and relapse from time to time; but for the last twelve months it has been gradu- ally extending itself, without any intervals of amendment; and now the health of the patient is much impaired. Although she has a good appetite almost uniformly, yet her weight has diminished to 139 pounds; the pulse is 100 per minute; the tongue clear; she complains of a constant feeling of lassitude and debility: her sleep has of late been more or less disturbed from cutaneous irri- tation, although she suffers no absolute pain. In examining the diseased skin, we will commence with that portion on which the eruption is in its incipient state, and then proceed to examine other districts, where it has existed for seve- ral months or years. On the lower part of the abdomen of the left side, and on the upper portion of the corresponding thigh, there are twelve or fifteen bright red spots of an oval shape, slight- ly but distinctly raised above the surrounding skin, and varying from one to two lines in diameter. They are hard to the touch; and, on being gently pressed, the color disappears and returns im- mediately on removing the finger. These papules were developed only two or three days ago. In this vicinity, also, are several dull-red blotches, some circular, and others oval-shaped, and vary- ing in size from the fourth to half an inch in diameter; nearly ah soft and pliable to the touch as the healthy surface. These blotches were preceded by papules of the same character as those just spoken of. So states the patient, 3 The next most recent development of the malady is upon the left chest. On this region it has existed three months, and occu- pies several square inches. It has the axilla for its outward bor- der in part, but it is quite irregular in its outlines. The surface here is of a dark livid color. There is considerable exfoliation of the cuticle from time to time. The first abnormal condition on this district consisted also of numerous papules, which remained but a few days, and then the skin gradually assumed the appear- ances now present. It is much thickened and somewhat uneven. The integument covering the superior and outer portion of the right scapula has a similar aspect to that of the left chest. The diseased patch is well defined, and is raised above the healthy sur- face, as in psoriasis, to which affection it bears considerable re- semblance. There is occasionally an exfoliation of the cuticle, but it is less furfuraceous than in psoriasis. The epiderma is de- tached, and falls off in shreds or flakes, produced by the friction of the clothing, which keeps the part somewhat raw and tender at several points. The eruption upon the part we are now consider- ing took place more than three years ago. It soon passed into, and has ever since maintained the character which it exhibits to- day, with no essential variation. No tubercles have ever formed in this locality. The next form of the disease which I shall attempt to describe consists of numerous tubercles (or tubers, as they are appropri- ately termed by Prof. Wilson in the last edition of his work on “Diseases of the Skin/’ London, 1857, page 92*). These tubers range from one line to more than one inch in diameter at the base, and are developed upon all the extremities, without any regularity as to their localization on corresponding portions of surface. The largest specimens are found on the front of the right knee. A few of them are solitary, and to a casual observer might suggest a slight resemblance to the immense thick crusts some- times seen in rupia. In fact, one or two medical students gave expression to this thought. Some of the tubercles are quite hard and unyielding to the touch; others soft and elastic. Some are considerably flattened; others are very prominent, and rise more * Wilson says that the tubers vary in size “ between a four-pcnny-piece and a shilling.” Wil- lis, in his “ Illustrations of Diseases of the Skin,” states that the “ size is that of a half-penny, a penny, or a crown piece." He has an excellent drawing representing the disease in its earliest stages. 4 than half an inch above the skin. Nearly all, wherever situated, are more or less movable, thus showing that the subcutaneous cellular tissue has not participated in the morbid action. When the pa- tient has been exercising, the diseased surface is of a much more brilliant red than at other times. Most of the time it has a deep livid or purplish color. There is no pain in any of the tubers,' but the patient has for the last few weeks been disturbed, espe- cially at night, by an itching and burning sensation in the affected parts. One tubercle, which came upon the outer aspect of the right fore-arm, near the elbow, some eighteen or twenty months ago, has disappeared, leaving the integument much thickened and livid, and within a few days a small new tubercle has begun to show itself on the border of the cicatrix left by its predecessor. Patient re- ports that during the last few months some of the biggest tuber- cles have flattened down and diminished in size, and subsequently have regained nearly their maximum growth. The most remarka- ble excrescences to be seen at this time are situated about the knee-joints, including the left popliteal space. In the right axil- lary region is a large group, each specimen being well-defined, distinct and projecting, and of the size of a small thimble at the base; likewise at the bend of the corresponding elbow is a clus- ter, covering a surface equal to a silver half dollar—the central tuber being as large as a common walnut, and having several smaller ones springing up around it. Nearly the entire surface of the right thigh is covered with the eruption, which presents a very remarkable appearance, consist- ing, as it does, of tubers, large and small, some crowded together in groups, or solitary—papules interspersed here and there—the skin hypertrophied, boggy, rough, and coarse, of a dingy red or purplish hue,shaded with a faint yellowish green tint, and the cuticle partially removed in some spots; all which would lead to the sup- position that much physical suffering must be the consequence. Yet such is not the fact. Even locomotion is not interfered with to any great extent. The patient is annoyed by a pretty constant pruritus, as in urticaria, but otherwise she experiences but very lit- tle local inconvenience. The complaint has made greater progress, and showrs more diversified features on this limb than elsewdiere, although all the extremities are seriously affected, as are likewise 5 various portions of the body. Occasionally there is moderate swelling (not cedematous) of the legs. This continues for a few days, and then subsides. Oct. 8th.—During the last fortnight, the cuticle has shown a tendency to exfoliate from the summit of many of the tubercles on the thighs and about the knees; and more or less serous exu- dation has escaped from the denuded surfaces, as in acute eczema. The tubercles thus bereft of their natural covering, are now ten- der to the touch, and quite painful. The patient finds it inconve- nient to walk any distance, and has in all respects failed since she came to the city. She desires to return to her friends before she becomes more feeble. She is much depressed in spirits, and fears she shall live but a few weeks. November 3d.—Under this date the patient writes me as fol- lows :—“ When I had been home a week, my right limb began to swell from my hip to my toes. The swelling lasted about eight days, and then began to go down. Since then it has been painful, and makes me lame to walk. The appearance of the sores is about the same as when I left Boston. They still continue to dis- charge a great deal of matter, and are more sensitive than they have been for a year before. The bunch on my right elbow is en- larged again. My appetite still continues good. J. B. Peck.” Remarks.—I have seen eleven cases of E. papulatum. In one, a young merchant of this city, the eruption continued three weeks and then vanished. In all the other instances the peculiar morbid diathesis persisted for many months. And in four instances the papules very gradually acquired the size and other attributes of E. tuberculatum. I had all desirable opportunities for observing the various and extraordinary phenomena that manifested them- selves in the progress of these four cases. There was great uni- formity in them; as much so as we find in the behavior of different cases of eczema, psoriasis, &c. I will not ask for time and space to describe all these phenomena, but will mention only the fol- lowing:—In each of the four cases to which I have just referred, there was an eruption of E. papulatum, which lasted for several months and then disappeared; and the individuals enjoyed usual health for a period varying from eigthteen months to three and five years. In each there was a second invasion of the disorder, which 6 ultimately passed into the more grave tubercular form, and in three instances terminated in death. The final result of the case exhi- bited to the Society to-night remains, of course, to be seen. The prognosis, however, is altogether unfavorable. I am not ignorant that a majority of writers who have anything to say upon the subject of erythema, tell us that it is not a dan- gerous or very serious affair in any of its varieties. Nevertheless, there are six fatal cases reported, besides those to which I have alluded in the preceding communication, and no amount of nega- tions can impair the force of these cases. They are derived from different sources, and would seem to be invested with an authority or evidence which it would be unreasonable to question. It so seems to me, at least. Willan, speaking of erythema tuberculatum, says, “I have seen but three cases of this latter disease, all of which terminated fa- tally.” (London edition, 1808, page 484.) Mr. Elliotson, of London, relates a fatal case of erythema that occurred in his prac- tice. Professor Wilson records one, and one occurred in St. George’s Hospital, London, in 1855. Yide British and Foreign Medico-Cliirurgical Review, October, 1856, page 497. Whoever will turn to “ Elliotson’s Principles and Practice of Medicine,” page 342, will find that he regards E. tuberculatum as a fatal malady; and that, in what I have offered, either now or hitherto,* I have assumed nothing. In connection with this communication, I desire to submit the subjoined note from Dr. C. Gordon, who has for many years de- voted special attention to the study and treatment of cutaneous diseases, and whose ability in this department is very generally acknowledged. *■ I refer to a case of E. tuberculatum et oedemntosum reported by me to the Society, and pub- lished in the Boston Medical and Surgical Journal for April 10, 1856 ; and in the Virginia Medical Journal for September, 1856, with two lithographic drawings. “Hancock Avenue, Nov. 13, 1860. “ Dear Dr.,—I am greatly obliged to you for the opportunity you lately afforded me to see the case of Erythema Tuberculatum in the person of Mrs. Peek. “ I have had occasion to observe very few cases of this remarka- ble form of cutaneous disease, in which, of late, you have been so much interested, and I never saw a case so well marked as the one above alluded to. “ The degree of tubercular or tuberous development must depend upon some peculiar constitutional element or disturbance, not un- derstood in these cases; and, therefore, I am not surprised that some observers have doubted whether the case in question is real- ly of the form of cutaneous disease you decided it to be. It is my opinion, however, that your diagnosis is correct, and I am hap- py to give my testimony in its confirmation. Yery truly, C. Gordon.” Dr. Durkce.